Finally, an important element in counseling is the way the counselor- patient interaction is perceived by both parties. New theories often place counselor and patient on an equal plane. Much of the education in health sciences emphasizes the need for the nutrition counselor to be separate and different from the patient. As nutrition counselors we are expected to be wiser, more professional, more balanced, and more experienced with greater ego strength. The nutrition counselor is in the role of the person who knows how to live a healthy lifestyle. The patient is the student who must learn from the teacher, the nutrition counselor. To be on an equal level with a patient means that the nutrition counselor has failed in some way, when just the opposite is true. Although the nutrition counselor has one level of knowledge, without the specific knowledge the patient brings to the counseling session, forward movement toward lifestyle change is impossible. Taking the position of the importance of including the patient in decision making during a nutrition counseling session has a major effect on the nutrition counselor and patient relation- ship. It allows for normalization of problems. Problems that the individual patient sees as unique become universal issues. In most nutrition coun- selor-patient situations the nutrition counselor is seen as strong and the patient weak. “I will help you change your nutrition lifestyle.” Instead, the nutrition counselor is willing to normalize what the patient is saying without ducking, despairing, rescuing, or running away.
In summary, research on new theories that include the addition of feelings relative to eating habits can play a large part in nutrition lifestyle change. The concept that the nutrition counselor and the patient are on equal footing working together as a team is also an important new direction needing more exploration in research studies.
REFERENCES
1. Baucom, D.H. and Aiken, P.A., Effect of depressed mood on eating among obese and nonobese dieting and nondieting persons, J. Personality Soc. Psy- chol., 41, 577–585, 1981.
2. Schotte, D.E., Cools, J., and McNally, R.J., Film-induced negative affect triggers overeating in restrained eaters, J. Abnormal Psychol., 99, 317–320, 1990.
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3. Cools, J., Schotte, D.E., and McNally, R.J., Emotional arousal and overeating in restrained eaters, J. Abnormal Psychol., 101, 348–351, 1990.
4. Fitzgibbon, M.L., Stolley, M.R., and Kirschenbaum, D.S., Obese people who seek treatment have different characteristics than those who do not seek treatment, Health Psychol., 12, 342–345, 1993.
5. Geliebter, A. and Aversa, A., Emotional eating in overweight, normal weight, and underweight individuals, Eating Behav., 3, 341–347, 2003.
6. Schlundt, D.G. and Zimering, R.T., The dieter’s inventory of eating temptations:
a measure of weight control competence, Addictive Behav.,13, 151–164, 1988.
7. Stunkard, A.J. and Messick, S., The Three-Factor Eating Questionnaire to measure dietary restraint, disinhibition and hunger, J. Psychosomatic Res., 13, 151–164, 1988.
8. Stunkard, A.J. and Messick, S., Eating Inventory Manual, San Antonio, TX:
Harcourt Brace Jovanovich, 1988.
9. Grilo, C.M., Shiffman, S., and Wing, R.R., Relapse crises and coping among dieters, J. Consulting Clin. Psychol., 57, 488–495, 1989.
10. Drapkin, R.G., Wing, R.R., and Shiffman, S., Responses to hypothetical high risk situations: do they predict weight loss in a behavioral treatment program or the context of dietary lapses?, Health Psychol., 14, 427–434, 1995.
11. Karlsson, J., Hallgren, P., Kral, J.G., Lindross, A.K., Sjostrom, L., and Sullivan, M., Predictors and effects of long-term dieting on mental well-being and weight loss in obese women, Appetite, 23, 15–26, 1994.
12. Carels, R.A., Hoffman, J., Collins, A., Raber, A.C., Cacciapaglia, H., and O’Brien, W.H., Ecological momentary assessment of temptation and lapse in dieting, Eating Behav., 2, 307–321, 2001.
13. Carels, R.A., Douglass, O.M., Cacciapaglia, H., and O’Brien, W.H., An ecological momentary assessment of relapse crisis in dieting, J. Consulting Clin. Psychol., 72, 341–348, 2004.
14. Byrne, S.M., Copper, A., and Fairburn, C., Weight maintenance and relapse in obesity: a qualitative study, Intl. J. Obesity, 27, 955–962, 2003.
15. Byrne, S.M., Copper, A., and Fairburn, C.G., Psychological predictors of weight regain in obesity, Behav. Res. Ther., 42, 1341–1356, 2004.
16. Roberts, R.E., Kaplan, G.A., Shema, S.J., and Strawbridge, W.J., Are the obese at greater risk for depression?, Am. J. Epidemiol.,152, 163–170, 2000.
17. Roberts, R.E., Strawbridge, W.J., Deleger, S., and Kaplan, G.A., Are the fat more jolly? Ann. Behav. Med., 24, 169–180, 2002.
18. Palinkas, L.A., Wingard, D.L., and Barrett-Connor, E., Depressive symptoms in overweight and obese older adults: a test of the “jolly fat” hypothesis, J.
Psychosomatic Res., 40, 59–66, 1996.
19. Carpenter, K.M., Hasin, D.S., Allison, D.B., and Faith, M.S., Relationships between obesity and DSM-IV major depressive disorder, suicide ideation, and suicide attempts: results from a general population study, Am. J. Public Health, 90, 251–257, 2000.
20. Siegel, J.M., Hyg, M.S., Yancey, A.K., and McCarthy, W.J., Overweight and depressive symptoms among African-American women, Prev. Med., 31, 232–240, 2000.
21. Roberts, R.E., Deleger, S., Strawbridge, W.J., and Kaplan, G.A., Prospective association between obesity and depression: evidence from the Alameda County Study, Intl. J. Obesity, 27, 514–521, 2003.
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22. Noppa, H. and Hallstrom, T., Weight gain in adulthood in relation to socio- economic factors, mental illness, and personality traits: a prospective study of middle-aged women, J. Psychosomatic Res., 25, 83–89, 1981.
23. DiPietro, L., Anda, R.F., Williamson, D.F., and Stunkard, A.J., Depressive symp- toms and weight change in a national cohort of adults, Intl. J. Obesity,16, 745–753, 1992.
24. Korkeila, M., Kaprio, J., Rissanen, A., Koskenvuo, M., and Sorensen, T.A., Predictors of major weight gain in adult Finns: Stress, life satisfaction and personality traits, Intl. J. Obesity Related Metabolic Disorders, 22, 949–957, 1998.
25. Cooper, Z., Fairburn, C.G., and Hawker, D.M., Cognitive-Behavioral Treatment of Obesity: A Clinician’s Guide,New York: The Guilford Press, 2003.
26. Mellin, L., The Solution, New York: Harper Collins, 1997, 158–161.
27. Telch, C.F., Agras, W.S., and Linehan, M.M., Group dialectical behavior therapy for binge-eating disorder: a preliminary, uncontrolled trial, Behav. Ther., 31, 569–582, 2000.
28. Telch, C.F., Agras, W.S., and Linehan, M.M., Dialectical behavior therapy for binge eating disorder, J. Consulting Clin. Psychol.,69, 1061–1065, 2001.
29. Linehan, M.M., Cognitive-Behavioral Treatment of Borderline Personality Dis- order, New York: The Guilford Press, 1993.
30. Brown, R.A., Lejeuz, L.W., Kahler, C.W., Strong, D.R., and Zvolensky, M.J., Distress tolerance and early smoking lapse, Clin. Psychol. Rev., 25(6), 713–733, 2005.
31. Hayes, S.C., Follette, V.M., and Linehan, M.M., Mindfulness and Acceptance:
Expanding the Cognitive Behavioral Tradition, New York: Guilford Publica- tions, 2004.
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14
SUMMARY
This text was devised to use research as a basis for our work with patients and their eventual nutrition lifestyle change. The goal was to provide realistic ways of changing dietary behaviors. We have much to learn relative to predictors of nutrition lifestyle change, but we also have many intervention-related concepts that point to ways in which we can achieve change.
Use of social cognitive theory and stages of change theory are discussed in this text with examples of ways to use each in maximizing the potential for nutrition lifestyle change. The patient-centered counseling is intuitive and often commonsense oriented. It focuses on the individual in whom the nutrition counselor is trying to facilitate change. Scripts in this text provide a road map to follow in working with patients where they are the focus. Figure 14.1 provides a summary of how a dietary intervention might occur. The counseling strategies discussed in previous chapters are presented in this concise diagram.
New research is needed in the area of emotions and the role they play in maintaining nutrition lifestyle change. The concept of inter nal disinhibition is discussed and may provide a methodology to use in helping persons who relapse because of feelings that trigger inappropriate eating behaviors and to use in forming appropriate coping mechanisms.
Teaching skills in changing coping methods can be a key to nutrition lifestyle change.
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Figure 14.1 Dietary intervention summary. (Courtesy of Steven Malcolm Berg-Smith, M.S.)
Stage 1 Not Ready Goal: to raise awareness Major task: inform and encourage -Ask key open-ended questions.
* “That’s interesting – why did you give yourself a 3 and not a 1?”
* “What would need to be different for you to consider making new or additional changes in your eating?”
* “You say you are a _____ on the ruler. What would have to happen to you for you to move from a ____ to a ____?” “How could I help get you there?”
-Respectfully acknowledge their decisions.
* “I respect your decision to not make any new or additional changes in your eating. You’re the best judge of what’s right for you.”
-Offer professional advice
* “As you might guess, my recommendation is that you ____.
But of course, it’s your decision. If there comes a time soon when you decide to make any new or additional changes with your eating.
I’m always available to help. In the meantime, I’d like to stay in touch.
Stage 2 Unsure Goal: to build motivation and confidence Major task: to explore ambivalence -Explore ambivalence.
* “What are some of the things you like (and dislike) about your current eating habits?”
* “What are some of the good (and less good) things about making a new or additional change?”
Look into the future.
* “I can see why you’re unsure about making new or additional changes in your eating. Let’s just stand back for a moment, and imagine that you decided to change. What would it be like? Why would you want to do this?”
-Refer to others
* “What do your friends or family like to eat?”
* “What would your friends or family think if you ate this way?”
-Ask about the next step
* “Where does this leave you now?”
(Let the patient raise the topic of change)
Stage 3 Ready Goal: to negotiate a plan Major task: facilitate decision-making -Identify change options
* “What do you think needs to change?”
* “What are your ideas for making a change?”
* “Which option makes the most sense to you?”
- Help patient set a realistic and achievable short-term goal.
- Develop an action plan.
- Summarize the plan.
- Complete “action plan” worksheet.
CLOSE THE ENCOUNTER -Summarize the session
* “Did I get it all?”
-Support Self-Efficacy
* “Again, I applaud your efforts and I know you can do it. If this plan doesn’t work out, I’m sure there are other options that might work better.”
-Arrange another time to meet
Establish Rapport
“How’s it going?’
OPENING STATEMENT
“We have ___ minutes to meet. This is what I thought we might do:
-Take your height and weight measurement.
- Hear how the new eating pattern is going for you.
- Give you some information from your last diet recall and cholesterol values.
- Talk about what if anything you might want to change in your eating.”
Tailor the Intervention Approach
Access Current Eating Behavior and Progress -Show Adherence Ruler
-Ask open-ended questions to explore current eating behavior and progress
* “Tell me more about the number you chose.”
* “Why did you choose a 5, and not a 1?”
* “At what times do you follow your new eating pattern, and at what times don’t you?”
* “How are you feeling about the new eating pattern?”
Give Feedback -Show participant feedback graphs and forms
-Compare participant results with normative data or other interpretive information
* “This is where you stand compared to other teenagers.”
-Elicit participant’s overall response: * “What do you make of all this information?”
-Offer information about the meaning or significance of the results (only if participant asks or shows interest)
ASSESS READINESS TO CHANGE -Introduce “change” ruler
* “On a scale of 1-12 [1 = not at all ready; 12 = very ready], how ready are you right now to make any new changes in your life to eat foods lower in saturated fat and cholesterol?”
* Ask participant to explain choice of number.
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Appendix A
WHAT YOUR BABY CAN DO AND HOW AND WHAT TO
FEED HIM
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140 Nutrition Counseling for Lifestyle Change
AgeDevelopmental LandmarksFeeding Suggestions Birth to 6 monthsSucks Roots for nipple Swallows liquids
Breast milk Iron-fortified infant formula 5 to 7 monthsHolds neck steady Sits with or without support Follows food with eyes Opens mouth when food is offered Draws in lower lip when spoon is removed Begins to swallow thickened food
Iron-fortified infant cereal Rice (start with first) Barley Mix with breast milk or iron-fortified infant cereal. Feed with spoon. Breast milk/iron-fortified infant formula 6 to 8 monthsSits without support Moves tongue to side Chews food with up and down motion Reaches for and palms food (palmar grasp) Begins finger feeding Begins drinking from a cup Well-cooked, mashed vegetables and fruits Sticky rice Unsweetened wheat-free dry cereals Corn tortilla strips Breast milk/iron-fortified infant formula
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What Your Baby Can Do and How and What to Feed Him 141
7 to 10 monthsBites off pieces of food Rotary chewing pattern Moves food from side to side in mouth Forms lips to cup Pincer grasp (thumb and forefinger) develops
Cooked or canned vegetables and fruits, chopped Cheese, cut up Cooked beans, mashed Pasta, cut into pieces Unsweetened dry cereals with wheat Toast squares, crackers, tortilla strips Breast milk/iron-fortified infant formula 9 to 12 monthsImproved pincer grasp Greater interest in solid foods Drinks from covered toddler cup without assistance
Soft cooked and raw foods, cut up Egg yolks, mashed Cheese, cut up Soft meats, fish, or poultry chopped Casseroles with any large pieces cut up Unsweetened dry cereals, toast, crackers Breast milk/iron-fortified infant formula 12 months and beyondBecomes more skillful at self-feeding Begins to use a spoon Increased sociability in regards to eating Soft table foods Whole eggs Whole pasteurized milk Modified from Kleinman, R.E., Ed., Pediatric Nutrition Handbook, 5th ed., American Academy of Pediatrics, 2004.
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Appendix B
PARENTAL FEEDING
PRACTICES INTERVENTION SESSION #1 — OVERHEADS
SESSION #1: INTERVENTION GROUP OVERHEADS
Parents influence a child’s behavior by …
Parental Modeling: Your own eating behavior. Example: You drink milk every evening with dinner.
Food Environment: The foods you make available to eat. Exam- ple: You buy applesauce and bananas every week to have at home to eat.
Feeding Practices: How you offer food or react to your child’s food intake patterns
Your infant is a unique individual, and if you handle feeding sensitively, you are helping your child to grow up to be a happy and healthy person.
People feel about eating and react to eating in many different ways that are all normal and acceptable and successful. You will be safe going along with your child’s eating behaviors, however odd they might seem.
Feeding with a Division of Responsibility
You are responsible for what your child is offered to eat and the way in which it is offered.
She is responsible for how much of it she eats, and even whether she eats.
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Parents are responsible for what is given to eat and the way in which it is presented:
Choose food that your child can handle, such as the right textures, so she can control it in her mouth and swallow it as well as possible; for example, starting cooked or canned fruits and vege- tables first. Also, you are responsible for what kinds of food are given, such as a variety of fruits and vegetables.
Hold your baby on your lap or support her in an upright position to introduce solids so she can explore her food. She’ll be braver about trying new foods.
Have her sit up straight and face forward. She’ll be able to swallow better and will be less likely to choke.
Talk to her in a quiet and encouraging manner while she eats.
Don’t entertain her or overwhelm her with attention, but do keep her company.
Children are responsible for how much and whether to eat.
Wait for him to pay attention to each spoonful before you try to feed it to him.
Let him touch his food — in the dish, on the spoon. You wouldn’t eat something if you didn’t know anything about it, would you?
Feed at his tempo. Don’t try to get him to go faster or slower than he wants to. Look into his eyes during the feeding process so you can share this experience with him.
Allow him to feed himself with his fingers as soon as he shows interest.
Stop feeding when he indicates he has had enough (turns head away, pushes plate or spoon away, won’t open mouth).
Children want to grow. They have built within them the need to get better at everything they do. Eating is no exception.
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Appendix C
PARENTAL FEEDING
PRACTICES INTERVENTION SESSION #2 — HANDOUTS
SESSION #2: INTERVENTION GROUP HANDOUTS
Feeding Your Baby Fruits and Vegetables Do …
Use cooked or canned fruits or vegetables at first. The heating process makes them less likely to cause allergic reactions.
Include fruits like those that are canned in water, juice, or syrup and then drained. Put the fruit through a baby-food grinder, mash it, chop it, or cut it into small pieces depending on your baby’s ability to gum and swallow.
Offer raw fruits such as peaches, pears, and plums once they have been eaten in their cooked form. Remove all skin and chop into small pieces.
Save time by giving your baby the cooked vegetables you are having at meals. Like fruit, put the vegetable through a baby-food grinder, mash it, chop it, or cut it into small pieces depending on your baby’s ability to gum and swallow.
Offer one new food at a time. Wait 2 to 3 days before adding another new food to check for allergic reactions.
Adjust serving sizes for your child’s age. In general, figure a serving equals 1 tablespoon of food per year of age. So a serving for a 1- year-old would be 1 tablespoon.
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Serve a variety of fruits and vegetables at meals and snacks. By the time your baby is 9 to 12 months of age, he needs a minimum of 2 servings of fruit and 3 servings of vegetables, or 5 servings from the fruit and vegetable group combined, to have a healthy diet.
Feeding Your Baby Fruits and Vegetables Don’t …
Offer your baby unlimited juice. While some juice is fine, too much can lead to cavities and leave your baby too full for other foods.
Choose a juice that is a good form of vitamin C, such as orange or grapefruit, or one that is fortified with vitamin C. Offer juice at snack times only, in a cup not a bottle. Limit juice to half a cup a day at first. If your baby wants more, dilute it with water to make it go further.
Feed your baby certain home-prepared vegetables such as beets, carrots, collard greens, spinach, and turnips when they are less than 6 months of age.
Feel you must use commercial baby foods. Commercial baby foods are OK to use, but they are not really needed. When buying commercial baby foods, read the label. Avoid those that have water as the main ingredient and contain a lot of carbohydrate fillers such as starches.
Feed your baby fruits or vegetables that she could choke on.
Foods that are unsafe include raw apple, carrot, or celery pieces.
Also, avoid whole grapes or cherry tomatoes — cut them into quarters instead.
Be alarmed if you notice changes in your baby’s stools after starting fruits and vegetables. It is normal for stools to change colors. It is also normal to see small lumps of food in your baby’s stools.
DIVISIONS OF RESPONSIBILITY
Parents are responsible for what is given to eat and the way in which it is presented:
Choose food that your child can handle, such as the right textures, so she can control it in her mouth and swallow it as well as possible; for example, starting cooked or canned fruits and vege- tables first. Also, you are responsible for what kinds of food are given, such as a good variety of fruits and vegetables.
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